Nokea
A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Urinary tract infection.
- C. Chorioamnionitis.
- D. Precipitous delivery.
Correct Answer: D
Rationale: Twin pregnancies increase the risk of precipitous delivery due to uterine overdistension, which can lead to rapid labor. Hypertension, infections, or chorioamnionitis are possible but less specific to twins.
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The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client panting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
- A. Tell the client to push between contractions.
- B. Provide gentle support to the fetal head.
- C. Apply gentle upward traction on the neonate's anterior shoulder.
- D. Massage the perineum to stretch the perineal tissues.
Correct Answer: B
Rationale: With the fetal head crowning, providing gentle support prevents rapid expulsion and perineal trauma. Pushing between contractions is incorrect, traction is for shoulder dystocia, and perineal massage is less urgent.
The physician orders docusate sodium (Colace) 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?
- A. Relief from episiotomy pain.
- B. Contraction of the uterus.
- C. Softening of the stool.
- D. Aid in sleeping.
Correct Answer: C
Rationale: Docusate sodium is a stool softener, which helps prevent straining during bowel movements, especially important after an episiotomy.
A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which of the following information should be part of this report? Select all that apply.
- A. Interpretation of the fetal monitor strip.
- B. Analgesia or anesthesia being used.
- C. Anticipated method of birth control.
- D. Amount of vaginal bleeding or discharge.
- E. Support persons with the client.
- F. Prior delivery history.
Correct Answer: A,B,D,E,F
Rationale: A comprehensive shift report includes fetal monitor interpretation, analgesia/anesthesia use, vaginal bleeding/discharge, support persons, and prior delivery history to ensure continuity of care. Anticipated birth control is not relevant during labor.
In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior(LOA) position?
- A. Near the symphysis pubis.
- B. Two inches above the umbilicus.
- C. Below the umbilicus on the left side.
- D. At the level of the umbilicus.
Correct Answer: C
Rationale: The transducer should be placed below the umbilicus on the left side for LOA position.
A client is considering the contraceptive implant. Which of the following benefits should the nurse highlight?
- A. It is effective for up to 3 years and reversible.
- B. It provides protection against STIs.
- C. It requires daily administration.
- D. It causes significant weight loss.
Correct Answer: A
Rationale: The contraceptive implant is effective for up to 3 years and is reversible, offering long-term convenience. It does not protect against STIs, require daily administration, or cause significant weight loss.